Removing contraception injection would lead to more deaths: study

Despite concerns that a contraceptive injection known as Depo-Provera increases the risk of HIV‚ withdrawing it from South Africa would increase maternal mortality and unsafe abortions‚ according to a new study.

Media reports last week highlighted concerns that the widely used injection is linked to a possible 40% increased risk of HIV infection.

It is thought the hormone contained in the contraception‚ Medroxyprogesterone acetate‚ may suppress the immune system and make it easier for the virus to travel through cells in a women's genital tract.

A new study in the journal Global Health: Science and Practice weighed up the issue of removing the injection‚ given every three months‚ as a contraception option from Sub-Saharan African countries.

The study found it would lead to an increased likelihood of maternal deaths across the continent‚ outweighing the risk of increased HIV infections and subsequent deaths. A lack of contraception can lead to increased maternal mortality‚ unwanted pregnancies and deadly abortions.

Last week‚ website Aids Map‚ using the study‚ explained if the injection was withdrawn from South Africa there would be 146 additional maternal deaths per 100‚000 women as a result of more pregnancies. That death toll is more than a modelled extra 117 HIV infections per 100‚000 women.

But does the three-monthly injection lead to an increased risk of HIV?

This publication spoke with the lead researcher on the study‚ American epidemiologist Dr Chelsea Polis.

It is important to note: a 40% increased risk doesn’t mean a 40% chance of getting HIV.

Q: Can you explain what increased risk means?

Polis explained: For example‚ based on the current HIV incidence rates in South Africa‚ a woman aged 15 to 24 who is not using Depo-Provera has about a 2.4% chance per year of contracting. If it does increase her risk by 40%‚ then using the hormone would increase her average chances of getting HIV to about a 3.3% chance per year.

Q: What is the risk for women living in areas of high HIV prevalence?

Polis explained that a woman in a low-income country having condom-less vaginal sex once a week with an HIV-positive male partner‚ who is not using antiretroviral therapy‚ has about a 14% chance per year of contracting HIV.

If the injection increases the risk of HIV acquisition by 40%‚ then using the injection would increase her average chances of getting HIV to about 19% per year.

Q: So what can women do?

According to the World Health Organisation‚ women should be given information on all the benefits and risks of different forms of contraceptives and be advised to use condoms during sex.

Polis explained that women should be made aware that Depo-Provera may potentially make her more vulnerable to contracting HIV if she is sexually active and has an HIV-positive partner‚ but the possibility is not 100% conclusive.

"She should be assisted to consider what this means in the context of her individual circumstances‚ and should be permitted to decide whether she would prefer to use this option‚ ideally in conjunction with a condom‚ or opt for an alternative method."

Q: The evidence of increased risk in humans is not conclusive‚ so what do people make of this?

Polis said: "This concern should neither be dismissed as unimportant‚ nor used to cause undue panic by failing to appropriately contextualise the issue or to understand the underlying evidence."

Q: What should countries do?

Polis said countries have to weigh up reducing the distribution of Depo-Provera contraceptive injections with the risk of "potential increases in unintended pregnancy and maternal/infant morbidity and mortality".

Polis on Twitter pointed to the study in journal Global Health: Science and Practice‚ which did modelling to look at what would happen if the injection were to be removed from Sub-Saharan Africa.

The study found it would be too difficult to change all people in Sub-Saharan Africa to different contraceptives and maternal mortality deaths would spike‚ as would unwanted children.

In the meantime‚ scientists are awaiting the results of the randomised control ECHO trial being conducted in South Africa‚ Zimbabwe and Kenya‚ which looks at this injection versus two other forms of contraception to see if it leads to an increased risk of HIV.